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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803904
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:24:57 PM


Document Has Been Signed on 03/10/2022 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216803904
ADMINISTRATOR:DOMIZIO, ANNEMARIEFACILITY TYPE:
740
ADDRESS:1465 S NOVATO BLVDTELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:118CENSUS: 78DATE:
03/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kathleen C. Olson - Executive DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of conducting a continue case management visit to delivery deficiencies and civil penalties.

During complaint investigation visit on March 3, 2022 LPA met with ED AnneMarie Domizio, toured parts of the facility, reviewed and obtained records for residents & staff; conducted interviews and made observations. Facility had 82 residents with 29 in memory care, and from 29 in memory care there are 3 under hospice care.
On 3/3/2022 facility tour at 13:00 hour with ED Annemarie Domizio, LPA observed the following:
· 3 out of 6 resident's bedrooms were not clean. Resident R1's room had clothes on the floor and bed had sheets pullout. ED stated that resident had an accident and room had not been cleaned yet. In addition, resident R2 had clothes all over the floor, bed not done, and a duty diaper on the top of toilet flush; and resident R3 had several duty Q-tips and tissue cleaner around the room. (see pictures, LIC 809-D, Civil Penalties)

· LPA reviewed files and observed that resident R1 was admitted on 11/23/2021 and has an LIC 602 dating 10/15/2021 without TB test results and/or clearance. LPA interviewed staff who wasn't able to find the documentation needed. R1's attached documentation to LIC 602 states "there is no flow sheet data to this plate". Facility found and submitted results on 3/4/2022. Facility understands that all documentation must be available on file for Department to review during a visit.

· LPA also observed on 3/3/2022 at 13:00 hour that memory care had 5 care staff with 1 being from an agency and 1 med tech; and at 15:00 hour facility memory care had 5 care staff with 4 being from an agency and 1 med tech. Records indicated that 4 out of 5 agency care staff are not associated to the facility (S1, S2, S3, and S4) with S4 also having fingerprint clearance pending. LPA contacted Regional Office who rechecked on Guardian and also stated the information above.

Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904
VISIT DATE: 03/10/2022
NARRATIVE
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· In addition at 15:00 hour, LPA returned to memory care and observed that facility had 1 agency staff and 1 med tech in MC dining area with 18 residents – med tech had to leave to help another resident that was trying to elope; 2 agency staff helping a resident who is 2 people assist; another 2 staff with 1 being from an agency helping another resident who is 2 people assist; activity staff was helping a resident R4 who showed up in the dining area wearing underwear, 1 shoe, and holding a pair of pants and asking staff for help.(see Complaint investigation 3/10/22 # 21-AS-20210824114946 )

· LPA also observed that resident R2 had unlocked bathroom cabinet with the following unlocked medications: Tums, Citrucel, and Philipps. (see LIC 809-D, Civil Penalties)

Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. Today's assessment of $250.00 is for the period of 6/18/21 through 3/10/22 - Title 22 Regulations #87705(f)(2)

Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. Today's assessment of $250.00 is for the period of 12/14/21 through 3/10/22 - Title 22 Regulations # 87303(a)

Immediate Civil Penalties are being assessed in the amount of $800.00 due to staff not being fingerprint cleared and/or associated to the facility - S1, S2, S3, & S4.

*****Total Civil Penalties issued today in the amount of $1.300,00


Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/10/2022 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:This requirement is not met as evidenced by:
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Based on obs. record review & interview, facility didn't comply w/section cited above in 4 outof 4 staff fingerprint clearance & association which poses an immediate health, safety or personal rights risk to persons in care.LPA reviewed staff S1,S2, S3, & S4 files, interviewed business director & learned that S1,S2,S3,S4 are not associated to the facility & S4 has fingerprint clearance pending.
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and that there are no other staff who is not fingerprint cleared &/or associated to the facility working by POC date of 3/11/2022 in order for the Department to clear this citation.
Type A
03/11/2022
Section Cited

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87705(f)(2)Care of Persons w/Dementia -The following shall be stored inaccessible to residents with dementia...This requirement isnt met as evidenced by: Based on observation the licensee did not comply w/section cited
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above in 1 of 1 memory care resident which is an immediately safety risk to person in care. LPA observed Tums, Citrucel, and Philipps for resident R2 in an unlocked bathroom cabinet on 3/3/22 during visit tour.
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that all items that constitute danger to residents are locked by POC date of 3/11/22. In addition, proof of MC staff training on Regulation #87705 by 3/24/22 in order to clear this citation. (Civil Penalties are being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2022 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216803904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited

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The facility shall be clean, safe, sanitary & in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees & visitors.
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This requirement is not met as evidenced by:Based on obs. licensee didn't comply w/section cited above in 3 out 6 resident's bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
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able to ensure that resident's rooms are clean and sanitary throughout of the day by POC date of 3/24/2022 in order to clear this citation. (Civil Penalties are being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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